Healthcare Provider Details

I. General information

NPI: 1982247433
Provider Name (Legal Business Name): LAQUETA NELSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3970 DEPUTY BILL CANTRELL MEMORIAL RD
CUMMING GA
30040
US

IV. Provider business mailing address

2400 HERODIAN WAY SE STE 220
SMYRNA GA
30080-8500
US

V. Phone/Fax

Practice location:
  • Phone: 678-513-2273
  • Fax:
Mailing address:
  • Phone: 770-383-1415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRN145567
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: